《诊断证明书》

1.旅客姓名

2.年龄

3.性别

4.住址(或工作单位)

5.电话

6.航程：航班号日期月

日自至

联程：航班号日期月

日自至

7.诊断结果：

8.症状、程度、愈后(如系孕妇需注明预产期) 注：(1)上述7、8两项内容填写，需简单、明确。

(2)下述表格中提供的内容。供机上服务人员在飞行途

医疗处理情况等，请予以列明)

已参阅背面的参考资料，我院诊断认为，该旅客的健康条

件在医学上能够适应上述航空旅行的要求，无传染疾病，

也不至造成对其它旅客的不良影响。

医师：电话：

签字医疗单位(盖章)

年月日

5．严重的中耳炎，伴随有耳咽管堵塞症的患者。

6．近期患自发性气胸的病人或近期做过气胸造影的神

经系统病症的患者。

7．大纵隔瘤，特大疝肿及肠梗阻的病人；头部损伤，

颅内压增高及颅骨骨折者；下颌骨骨折最近使用金

属线连接者。

8．酒精或其他毒品中毒者；患有精神病；易于伤人或

自伤行为者。

9．近期进行过外科手术，伤口未完全愈合者和产妇后

不满二周者。

10．在过去30天内患过脊髓型脊髓灰质炎患者。

11．下列传染病或疑难病患者：

霍乱、伤寒、付伤寒、发疹性斑诊伤寒、痢疾、天花、猩

红热、白喉、鼠疫、流行性脑炎、脑膜炎、开放期的肺结

核及其他传染病。

12．带有传染性或损伤、使其它旅客感到厌恶的皮肤病

患者。

13．带有严重咯血、吐血、呕吐、呻吟症状的患者。

MEDICAL CERTIFICATE FOR AIR TRAVEL

1.Passenger’s Name

2.Age

3.Sex

4.Address:

5.Telphone:

6.Airlines,flight

number and date From to

(If interline: Carrier From to

7.Diagnosis：

8.Symptoms,severity and immediate prognosis(In case

of a pregnant woman, put the expected delivery date)

Note: i) The medical terms used in Item 7 and 8

above should also be explained in simple words.

ii) The following table should serve as a

guidance for cabin attendants in the treatment

of the invalid passengers in flight. Please

malfunction of the bladder or bowels, or any

special diet or medication required in flight) 10.Meas of carriage (encircle an appropriate item

Having read the guiding principles on the reverse

side of this page, I diagnose that this passenger

is medically fit to undertake the above journey by

air; is non-infectious and has no malady which

might cause distress, inconvenience or embarrassment to other passengers.

Doctor’s Name (Signature) Issuing Date

GUIDANCE FOR THE PHYSICIAN

The following factors to be considered when diagnosing the physical and mental fitness for air travel:

1. Cabin conditions:

a) The air pressure within the pressurised cabin

may fall to the equivalent of a height of 2300 meters (7000ft) with consequent expansion of any gas within body cavities and reduction of alveolar oxygen pressure.

b) Technical limitations of space and comfort.

c) Cabin attendants are trained only in First

Aid and not allowed to give injections.

Furthermore, they not expected to pay

particular attention to the invalid people

to the detriment of service to other

passengers.

d) The activity range and comfortable degree are

specially restricted by the technological equipment in the cabin.

2. Person under following condition are generally